REKTUM YARALANMALARINDA PROGNOSTÝK FAKTÖRLER

Sivil rektal yaralanmalarýn tedavisinde, fatal septik komplikasyonlarýn geliþimini önlemek amacýyla saptýrýcý kolostomi ve perirektal dokularýn drenajý gereklidir. Rutin distal rektumun yýkanmasý ve rektumun primer tamiri halen tartýþma konusudur. Bu amaçla, rektum yaralanmasý nedeniyle son 10 yýllýk dönem içinde kliniðimizde tedavi edilen 19 olgu yaþ, cinsiyet, yaralanma þekli, yaralanma anýndan tedaviye dek geçen süre, travma skorlarý (Abdominal Travma indeksi, Düzeltilmiþ Travma Skoru, Yaralanma Þiddet Skoru, Rektal Yaralanma Skoru), ek organ yaralanmalarý varlýðý, uygulanan cerrahi prosedürlerin morbidite ve mortalite geliþimine etkisi açýsýndan chi-kare, Fischer kesin olasýlýk testi ve lineer regresyon analiz yöntemleri ile retrospektif olarak deðerlendirilmiþtir. Yaralanma nedeni 12 (%62.2) olguda künt travma, diðer olgularda ateþli silah yaralanmasý idi. ATY ortalamasý 24.3, YSS ortalamasý 32.6, DTS ortalamasý 5.5 olarak hesaplanmýþtýr. ATÝ>27 ve YSS>40 olan olgular ile yaralanma anýndan tedavi edildiði döneme kadar geçen sürenin 24 saati aþtýðý olgularda, geliþen morbiditenin oraný istatistiksel olarak anlamlý bulunmuþtur. Rektum yaralanmak olgularda, geliþen morbiditenin oraný istatistiksel olarak anlamlý bulunmuþtur. Rektum yaralanmak olgularýn 7 (%36.8)'sine rektal tamir, 6 (%31.5)'sýna distal rektal yýkama iþlemi uygulanmýþtýr. Presakral drenaj olgularýn 18 (%94.7)'üne, diverting kolostomi ise olgularýn tümüne uygulanmýþtýr. Toplam morbidite oraný %52.6, mortalite oraný %10.4 olarak saptanmýþtýr. Kýsýtlý sayýda hasta grubuna dayanmasýna raðmen, uygulanan cerrahi iþlemlerin, morbidite geliþimine etkisi anlamlý bulunmamýþtýr. Bu konuda çok merkezli prospektif randomize çalýþmalara gereksinim vardýr.

PROGNOSTIC FACTORS IN RECTAL INJURIES

Current management of civilian rectal injuries mandates complete fecal diversion and presacral drainage of the presacral drainage of the presacral tissues to prevent fatal septic complications. Routine distal colon washout and primary repair of the rectum still remains challenging problems in the management. In an effort to elucidate these issues, we reviewed 19 patients with rectal trauma over the last 10 years. Rectal injury was due to gunshot wounds in 7 (36.8) patients, blunt trauma in 12 (62.2) patients. The mean Revised Trauma Score 5.5, Abdominal Trauma Index 24.3, and Injury Severity Score 32.6. Proximal colostomy was done in all patients and presacral drains were placed in 18 (94.7%). Broad spectrum antibiotics were administered for a minimum 5 days. Primary rectal repair was performed in 7 (36.8%) and distal rectal washout in 6 (31.5) patients. Patients were evaluated with respect to injury mechanism, shock on arrival, missing time from injury to therapy, rectal wound severity, associated injuries, perioperative blood transfussions, trauma scores and surgical procedures by using uni-and multi-variate analysis. Total morbidity rate was 52.6%, mortality rate 10.4%. Delayed surgery more than 24 hours and high trauma scores (ATI>27 and ISS>40) were the significant factors on morbidity. Although based on a small group of patients, surgical procedures such as distal rectal washout and primary repair of the rectum had no significant effect on prognosis. Ultimate resolution of these issues demands a multicenter prospective randomized trial.